Why Obamacare repeal faces possible revote in the House

WHY OBAMACARE REPEAL FACES POSSIBLE REVOTE IN THE HOUSE — It's been two weeks since House Republicans celebrated in the White House Rose Garden … but the bill they were applauding still hasn't been sent to the Senate.

Why not? House leaders are hanging onto the American Health Care Act "out of an abundance of caution," a leadership source told POLITICO's Kyle Cheney and Jen Haberkorn, with the Congressional Budget Office expected to release its score on the revised bill next week.

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Among the potential pitfalls, first reported by Bloomberg News:

1. The CBO could determine that the revised bill doesn't reduce the deficit by $2 billion — with the savings equally split between the Senate HELP and Senate Finance Committees — which would disqualify it under budget reconciliation.

2. The bill also may not provide savings after a decade, which could also disqualify it.

Republicans say they're confident that the bill will be scored favorably, given that the earlier version of AHCA was projected to reduce the deficit by $150 billion over a decade. But the MacArthur amendment — finalized just days before the vote — allows states to pursue broad waivers that throw in many variables.

Under one possible — if unlikely scenario — enough states could pursue waivers that ultimately drive up enrollment and tax credit spending, and lead the bill to actually increase the deficit. (That scenario was described by the Center for a Responsible Federal Budget and detailed in POLITICO earlier this month.)

… Re-voting on the bill could be a catastrophe for House Republicans, given the narrow 217-213 margin when AHCA passed in May, given the likelihood that the pending CBO score will again predict major coverage losses and potentially scare off moderates or at least provoke a big fight.

… There's no small amount of irony here for Republicans. If the American Health Care Act succeeds at the party's stated goal — encouraging millions more people to sign up for coverage — it becomes more expensive. House leaders also plowed ahead before the final CBO score, saying it was unnecessary, only to be held up by it regardless.

GOP GROUP OUTSPENDING DEMOCRATS 4-TO-1 ON HEALTH CARE ADS — That's the takeaway from POLITICO's Scott Bland, who looked at House districts and tallied up the $8 million in targeted spending from the American Action Network — which is backing the American Health Care Act — versus the less than $2 million from pro-ACA groups Save My Care and Patriot Majority USA.

… Republicans' advertising advantage has frustrated some Democrats, Scott reports. They want to see their party take full advantage of favorable polling on health care and push the issue early — much as Republicans did against them before the 2010 and 2014 elections.

“This is a deeply unpopular piece of legislation, but the electorate is not fully aware of what it does and it is not at the top of people’s minds,” said Jon Vogel, a Democratic strategist.

THANK GOODNESS IT'S FRIDAY PULSE — Where we've got an update on the story gripping the nation: Miss USA does think health care should be a right for all. (The newly crowned pageant winner says she misspoke when she said it was a privilege.)

PULSE CHECK: How POLITICO’s editor thinks about Trumpcare, Obamacare and this crazy news moment. How does a major outlet stay focused on health care’s policy fights when Russia’s the talk of the town? Carrie Budoff Brown would know — she’s the editor of POLITICO and was one of the top reporters covering the health care debate in 2009-2010.

(Carrie should be extra-familiar to some readers — she was one of the founding writers behind PULSE.)

In this episode of the “Pulse Check” podcast, Carrie shares takeaways from her reporting on Obamacare, how she sets newsroom strategy today and how she responds to some of the most frequent questions from listeners — like when it’s appropriate to use the word “lie” when talking about the president. Listen to the podcast.

IN CONGRESS

GOP idea for phasing out Medicaid expansion could backfire. Republican moderate Sen. Rob Portman is trying to extend the program's life in the chamber's repeal bill … but the plan may still inflict budgetary pain and coverage losses, Pro's Rachana Pradhan reports.

— How it would work: Portman's plan would phase out Medicaid expansion dollars over five years after 2020, a more gradual off-ramp than the House's version, which after 2019 only preserves expansion funds for people continuously enrolled in the program and blocks money for new enrollees.

— Why it could backfire: Eight states have triggers to end their expansion program in the event of federal funding cuts: Arkansas, Arizona, Illinois, Indiana, Michigan, New Hampshire, New Mexico, and Washington state.

And the effect could quickly spread to other states fearing the eventual loss of federal funds. “Everybody would be screaming and yelling all that time,” said former Arizona Gov. Jan Brewer, a Republican who pushed Medicaid expansion through the state Legislature in 2013. Keep reading: More for Pros.

** A message from PhRMA: Why not let patients benefit? New analysis reveals sharing all of negotiated discounts could save certain commercially insured patients $145 to more than $800 annually and would increase premiums on average 1 percent or less. Learn more: http://onphr.ma/2hBVaIb **

FIRST IN PULSE: Bob Casey and Chuck Grassley prepping bill for 'medical nutrition equity.' The Pennsylvania Democrat and the Iowa Republican plan to introduce legislation next week that would provide public and private insurance coverage for medically necessary foods — essentially, specialized foods for patients with digestive and metabolic disorders like cystic fibrosis or Crohn's disease.

Patients with these disorders can suffer serious health care consequences — and even death — if they don't consume customized foods. But health insurance doesn't always cover it.

… Public health researchers offered qualified praise for the legislation. "It's nice to see food being recognized as a key input to health. That's movement in the right direction," Lauren Taylor, the co-author of "The American Health Care Paradox," told PULSE. "Not everything that makes us healthy need be medical."

THE WHITE HOUSE

Joe Lieberman's potential return is vexing Democrats still angry about health care. The former Connecticut senator is in the running to be Trump's FBI director, but his ex-colleagues aren't greeting the idea warmly — partly because of his health care history, Burgess Everett and Seung Min Kim report.

"He’s the reason we lost Medicare at 55 … Couldn’t have had anything to do with the insurance industry lobbying in Hartford," Ohio Sen. Sherrod Brown said on Wednesday, referencing Lieberman's decision in 2009 to oppose a Democratic proposal to extend Medicare to people 55 and older. "I’m sure Lieberman couldn’t succumb to that," Brown added sarcastically.

AROUND THE NATION

Covered California to hold three-month open enrollment period. Word that Obamacare is failing apparently hasn't reached California, POLITICO's Victoria Colliver reports from the Golden State. Covered California is preparing for a three-month open enrollment period this fall — twice the length of the new planned HealthCare.gov enrollment — and the exchange is operating solidly in the black.

HHS's latest rules on the insurance markets "very clearly provide that the state-based marketplaces will be given discretion to do what's right in their states," said Peter Lee, the exchange's executive director, adding that his plan to extend California's enrollment period has received support from CMS officials. More for Pros.

California: How ACA affected self-employed, small businesses. A new report from UC Berkeley’s Labor Center shows how more than a million small business employees and over half a million self-employed Californians benefitted from the ACA, either from expanded Medi-Cal or the subsidized coverage through the state-run exchange. The percentage of uninsured self-employed Californians dropped from nearly 34 percent in 2013 to less than 18 percent in 2015. Employees in businesses with fewer than 50 workers saw similar drops.

Levey's story included a claim that CMS administrator Seema Verma asked insurers to support the GOP bill in exchange for getting Obamacare subsidies funded, and TPM's Tierney Sneed summarizes the issue. More. It's worth noting: CMS has loudly denied that claim, with one staffer who was in the room saying that it's absolutely false.

** A message from PhRMA: A new Milliman analysis reveals providing access to discounted medicine prices at the point of sale could save certain commercially insured patients with high deductibles and coinsurance $145 to more than $800 annually. The data also show a minimal impact on premiums given those plan costs would increase on average 1 percent or less if all of negotiated rebates were shared with patients. Negotiations between biopharmaceutical companies and health plans result in significant rebates. In fact, more than a third of the list price for brand medicines is rebated back to payers and the supply chain. These rebates created savings of more than $100 billion in 2015 and grow every year. Why not let patients benefit? Learn more at www.LetsTalkAboutCost.org. **

About The Author

Dan Diamond is the author of "POLITICO Pulse," the must-read morning briefing on health care politics and policy. He's also the creator of PULSE CHECK, the popular podcast that features weekly conversations with some of the most interesting and influential people in health care — a show that's become "the Charlie Rose of health care," says Andy Slavitt, who ran Medicare, Medicaid and the Affordable Care Act under President Obama.

Before joining POLITICO, Diamond edited the Advisory Board Daily Briefing, served as the Advisory Board's senior director of news and communications and created and hosted the popular Weekly Briefing health care podcast. He also covered health care policy, business, and strategy for FORBES. His work has appeared at Vox, Kaiser Health News and other publications.

Diamond is a graduate of the University of Pennsylvania and has appeared to discuss health care, politics, and policy on NPR's "All Things Considered" and "1A," the NBC Nightly News, the BBC, CBS, MSNBC, the Dan Patrick Show, KQED's "Forum" and other programs. He was recently named a 2015-2016 fellow of the Association of Health Care Journalists.